Healthcare Provider Details

I. General information

NPI: 1912233875
Provider Name (Legal Business Name): WELDON COOKE MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2009
Last Update Date: 12/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10176 W. 400 NORTH SUITE C
MICHIGAN CITY IN
46360
US

IV. Provider business mailing address

3965 N. MALAGA DR
LAPORTE IN
46350
US

V. Phone/Fax

Practice location:
  • Phone: 219-873-1777
  • Fax: 219-873-0001
Mailing address:
  • Phone: 219-873-1777
  • Fax: 219-873-0001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01020627B
License Number StateIN

VIII. Authorized Official

Name: WELDON JOHN COOKE
Title or Position: OWNER- MD
Credential: MD FACS
Phone: 219-871-2500